This study examined the implementation of a tool integrated into the electronic health record to export surgical discharge data to an adverse event reporting platform. The tool demonstrated high sensitivity and specificity when compared to a chart audit and identified a higher proportion of adverse surgical events than traditional reporting mechanisms. The authors recommend implementation of these automated reporting mechanisms.

Incident reporting systems are widely implemented in health care systems, but they are often underutilized by clinicians. This institution implemented a psychiatry-specific incident reporting tool. Researchers found that physicians submitted more incident reports but there was no significant change in how many serious harm events were identified. An Annual Perspective described the challenges in measuring and responding to serious patient harm.

Engaging physicians in voluntary safety reporting has generally been challenging. In this study, internal medicine residents reported many more clinically significant events following the introduction of an easy-to-use mobile platform that combined event reporting with patient signout.

Journal Article > Commentary

This review discusses chart reviews, trigger tools, and voluntary reporting as approaches to monitor adverse events and explores how lack of a standard method to collect and analyze data can hinder progress in determining trends and learning from reported information.

To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.

The Institute for Healthcare Improvement's Global Trigger Tool has been used to quantify the incidence of preventable harm in seminal studies. This study describes how a large health system used the Global Trigger Tool to identify causes of preventable harm, track adverse event rates over time, and guide improvement efforts. Through a standardized assessment and dissemination process, this health system achieved reductions in preventable adverse events across its 25 hospitals over a 2-year period. Although the Global Trigger Tool is widely used, concerns have been raised about its reliability, and it is generally recommended that organizations should use multiple methods of detecting safety hazards to gain a comprehensive picture of patient safety.

Despite numerous studies over the past three decades, one fundamental patient safety question remains controversial: what proportion of hospitalized patients are harmed by medical care? Prior estimates range from approximately 3% to nearly 17%, but this study found that nearly one-third of patients experienced an adverse event during hospitalization. This study used the Institute for Healthcare Improvement's Global Trigger Tool to detect adverse events and also found that this trigger tool identified significantly more adverse events than voluntary reporting or the AHRQ Patient Safety Indicators. An important caveat is that this study did not assess whether the adverse events detected were preventable. Nevertheless, the results do raise the concern that adverse events remain common despite enhanced safety efforts. The challenges of accurately measuring patient safety events were discussed in an AHRQ WebM&M perspective.

Adverse drug events have been documented as a significant problem in inpatient psychiatric facilities, but methods of preventing errors in this setting have not been researched. This study, conducted at an academic inpatient psychiatric hospital, combined a computerized provider order entry system with a structured event reporting system that was used by physicians, nurses, and pharmacists. Implementation of the system was associated with a significant reduction in both prescribing errors and medication administration errors over a 5-year period.

Journal Article > Study

This study describes the development and validation of a web-based tool that allows families to report adverse events during pediatric hospitalizations. The most frequent reports filed were around miscommunication between staff.

Perspectives on Safety > Interview

Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.

The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.

Journal Article > Study

The authors assessed residents' incident reporting using personal digital assistants (PDAs) and found that the technology, supported by a blame-free environment, contributed to the strong response by the trainees.

Newspaper/Magazine Article

This "Health for Life" series features 10 case studies about patient safety and quality improvement efforts as well as several short articles on safety-related topics such as disclosure and computerizing medical care.

Journal Article > Study

This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.

Journal Article > Study

This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. The investigators aimed to create an easy-to-use system that assists in characterizing captured incidents and allows opportunity for feedback. Discussion includes details of the design features, a table of the system-based factors contributing to reported incidents, and several screen shots of the reporting system itself. Initial data collected after implementation demonstrated wide variability in use, but consistency existed in the types of incidents reported—nearly one of every two being a near miss. The authors suggest that wide adoption of this type of reporting system, coordinated by a professional organization, may lead to data-generated improvements in care.

Cases & Commentaries

Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.